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ILLINOIS WORKERS' COMPENSATION COMMISSION
100 W. Randolph St. #8-200 Chicago, IL 60601-3227 312/814-6611 Toll-Free in IL: 866/352-3033
WWW.IWCC.IL.GOV
PAT QUINN GOVERNOR AMY J. MASTERS ACTING CHAIRMAN

Date _________________________

You have received these instructions because you have expressed an intention to represent yourself on your workers' compensation case. If you do proceed without an attorney (called "pro se," or "for oneself"), it will be your responsibility to handle your case according to the law and rules. The IWCC cannot give you legal advice. You will need to refer to the following documents: 1. Illinois Workers' Compensation Act 2. Rules Governing Practice Before the Commission 3. Handbook on Workers' Compensation and Occupational Diseases These documents, and all necessary forms, are available at all IWCC offices, through the mail by request, and on the IWCC web site. There is no fee to obtain forms or to file a workers' compensation claim. HOW TO FILE A CLAIM By law, an Application for Adjustment of Claim must be filed within three years from the date of injury or two years from the last workers' compensation payment, whichever is later. 1. Answer all questions on the application. 2. Complete the "Proof of Service" section on the back, including the employer's name and address. You must have your signature notarized. 3. Mail or deliver a copy of the signed application to your employer. 4. Send or deliver three copies of the signed application to the IWCC. 5. Keep one copy of the signed application for your records. HOW TO KEEP TRACK OF YOUR CLAIM After you properly file the Application, the IWCC will mail all parties a Notice of Hearing, indicating the arbitrator who has been assigned to the case and the date that the case will first come up for a status call. After the first status call, the case will automatically come up for another status call every two months. You will not receive a notice of the next call date; it is your responsibility to keep track of subsequent status call dates. You may check the status call dates on the IWCC's web site, or you may call the Information Unit. This continuance process will continue for three years, unless a party asks the arbitrator to act on the case. For the first three years, you do not need to attend the status call unless you request a trial or ask the arbitrator to act on your case. If your employer requests a trial and sends you a copy of the request, you need to attend the call. After three years, you must go to trial unless you can show good reason why your case (now called a red-line case) should stay open. Every time your case comes up for a status call, you must appear at the status call and complete the Arbitration Case Information Sheet, explaining why the case cannot go to trial but should not be dismissed.

HOW TO REQUEST A TRIAL 1. Complete the Notice of Motion and Order. In the first blank space, enter your next status call date. In the second blank space, enter the time: Chicago status calls are held at 2 p.m., while Downstate calls are held at 9 a.m. Check the "Request for hearing" option. 2. Complete the "Proof of Service" section on the back of the form, including the employer's name and address. You must have your signature notarized. 3. Complete the Request for Hearing. Fill in all the "Petitioner claims..." questions on both sides of the form. 3. Mail or personally deliver one copy of the Notice and the Request to your employer 15 days before the status call date set forth in the Notice.* 4. File the Notice and the Request with the IWCC. 5. Keep one copy of the Notice and Request for your records. At trial, you may need to provide evidence on the following issues: a) Employment: on the date of the accident, a relationship of employee and employer existed between the parties. b) Accident or exposure: you sustained accidental injuries or were exposed to an occupational disease that arose out of and in the course of employment. c) Causal connection: the medical condition was caused or aggravated by the alleged accident or exposure. d) Notice: the employer received notice of the accident or exposure within the time limits set by law. If you prevail on these issues, you will generally qualify for some benefit, but there may be other issues in dispute: for example, the parties may disagree over the extent of your disability, or your average weekly wage, or whether the medical treatments and/or bills were reasonable and necessary, etc. HOW TO REQUEST AN EXPEDITED TRIAL UNDER SECTION 19(b) OF THE ACT If you believe you are owed 12+ weeks of Temporary Total Disability benefits, you may request an expedited hearing under Section 19(b) of the Act. 1. Complete the Notice of Motion and Order. In the first blank space, enter the arbitrator's next status call date. In the second blank space, enter the time: Chicago status calls are held at 2 p.m., while Downstate calls are held at 9 a.m. Check the "Hearing under Sect. 19(b)" option. 2. Complete the "Proof of Service" section on the back of the form, including the employer's name and address. You must have your signature notarized. 3. Answer all questions on both sides of a Petition for an Immediate Hearing Under Section 19(b) of the Act. 4. Send or personally deliver a copy of the Notice and the Petition to your employer 15 days before the status call date set forth in the Petition.* 5. File the signed Notice and the Petition, along with a copy of the filed Application, with the IWCC. 6. Keep one copy of the Notice and the Petition for your records.
* If you do not follow this requirement properly, the arbitrator will not set the case for trial. 4/16/09